History

The patient is a 74-year-old female who presents with 9 months of back and right greater than left leg pain. Four years ago, she underwent anterior lumbar interbody fusion (ALIF) with pedicle screws at L4-S1. Her Oswestry Disability Index (ODI) is 20.

Her past medical history includes borderline diabetes, obesity, and hypertension. She is a nonsmoker.

Case Discussion

Doctors Ammerman and Wind illustrate a problem that most experienced spine surgeons experience with monotonous regularity—adjacent segment failure after prior fusion. The authors are to be congratulated on an excellent surgical, radiological and clinical outcome with their targeted MIS approach.

There are many ways to ‘skin this cat’, which includes various posterior or lateral approaches; perhaps anterior or combined with or without interbody fusion, open, mini-open or MIS. No result is better than the other in a definitive fashion. The surgeons in this case report have shown a high level of skill which, in their hands has shown an excellent outcome. Every surgeon will need to find their level of comfort in deciding what works for them.

Hello! I just wanted to know how did you took out the previous transpedicular system the patient had....? In the preop X rays we can see transpedicular screws at L4 and S1 and the PO images shows different construct...

The prior L4-S1 screws were removed as follows. Paramedian incisions 1.5 inches in length were opened bilaterally over the screw heads based on fluoroscopy. The fascia was opened and then an expandable MIS retractor (Quadrant, Medtronic) was inserted and expanded to expose the screws and rod. The implants were then removed with standard tools

This is an approach I've been using for about a year and a half now with similar results. I use stab incisions over existing hardware to remove the existing hardware. I then dock a 20 or 22mm tube over the facet joint at an approximately 35-40 degree angle. By removing the superior articular process (removing the inferior articular process may also be necessary for lateral recess decompression and sublaminar/contralateral decompression) you can access the disc space as described.
I concur that average EBL is about 50cc for the index level and average hospital length of stay is 1.5 days. I commend the authors for describing this approach as it a successful, minimally-invasive approach for TLIF, including for adjacent segment breakdown.